diagnosis: stemi info for the community. my roots (north of the homestead) devils lake = home devils...
TRANSCRIPT
Diagnosis: STEMI
Info for the Community
My Roots (North of the Homestead)
Devils Lake = Home
Devils Lake = Home
FYI: ND has 4 PCI centers…
2 1
4 3
North Dakota – The Four “F’s”
F1) Freezing…
Coldest temp inDevils Lake last year?
-32 degrees (below zero)
North Dakota – The Four “F’s”
F2) Farming…
Life in the “Vast Lane”
North Dakota – The Four “F’s”
Snow plow on Devils Lake…
Ice House
Ice = 3.5’
F3) Fishing (ice)
North Dakota – The Four “F’s”
F4) And Flooding…
1997 Red River of the North flooding Grand Forks, ND
Photo: “Come Hell or High Water” (left) won Pulitzer Prize
ST-Segment Elevation Myocardial ST-Segment Elevation Myocardial Infarction (STEMI) =BAD!Infarction (STEMI) =BAD!
What is a STEMI?
A suddenly clogged artery to the heart May happen without warning High risk of death or permanent injury Symptoms are not always chest pain Treatment is opening of the artery
Drano (thrombolytics)
Roto-Rooter (angioplasty)
Lesson: Avoid “Fred Sanford Syndrome”
Not everyone with a heart attack has “chest pain!”
How do you diagnose STEMI?
Its very simple: Do an ECG
ST elevation on the ECG defines the disease
ST elevation is an acute emergency trigger for something…….
STEMI: A Needle in the Haystack
STEMI cases are few and far between
Without Recognition there can be no Reperfusion
So, you have to do a lot of ECG’s!
!
…Its a cost of doing business!
Another Bad ECG!Another Bad ECG!
No Recognition = No Reperfusion!
STEMI 2010: “60 is the New 90”
Gersh BJ, et al. Gersh BJ, et al. JAMAJAMA. 2005;293:979-986.. 2005;293:979-986.
00
2020
4040
6060
8080
100100
1212 2424Time From Symptom Onset to Reperfusion TherapyTime From Symptom Onset to Reperfusion Therapy
(hours)(hours)
Mort
ality
Red
ucti
on
, (%
)M
ort
ality
Red
ucti
on
, (%
)
Mortality Mortality Reduction (%) (%)
Extent of Salvage(% of area at risk)
D-B – Harm
A-B – No Benefit
Shifts in Potential
Outcomes
A-C – BenefitB-C – Benefit
D-C – Harm
00 44
DD
CC
BBAA
88 1616 2020
i.e. 44 is better than 66!!!
The “STEMI Care Continuum”The “STEMI Care Continuum” Cemented by Relationships! Cemented by Relationships!
THE PATIENTTHE PATIENT EMS personnelEMS personnel ED triage personnelED triage personnel Medical CommandMedical Command ED nursing staffED nursing staff ED physician ED physician EMS transfer staffEMS transfer staff Paging system personnelPaging system personnel Cath lab staffCath lab staff CardiologistCardiologist Quality Improvement staffQuality Improvement staff
Reperfusion!
Recognition!
Relationships
The Cardinal Rule: Once STEMI is identified it must trigger a clear response downstream!
ECG Acquisition
Communication
EMS Evaluation
Decision!
I. Remember…Most of the Time
…the easy ones are easy!
So, make more of them easy!
II. STEMI Fact: If it Can Go Wrong, it Will (sooner or later)
Leave nothing to chance!
Approach STEMI systems building like a system’s engineer…
Don’t try to error-proof your providers. Error-proof your system!
III. STEMI 2010: There is NO New Frontier!
Every STEMI case has the same fixed endpoints (R2R)
Model success, but don’t copy it! (???)
Adapt principles to the situations not vice versa!
Recognition to Reperfusion
TRUTH: Without early recognition there can be no progress towards early reperfusion
The focus must be on the earliest possible recognition followed by fast and precise reperfusion
Again, it all begins with Recognition!
However, it is as it is….
Several reasons why pre-hospital STEMI
care will always remain a challenge…
Rokos et al. J Am Coll Cardiol Intv, 2009; 2:339-346
All Americans are Not Distributed Equally!
All Americans are Not Distributed Equally!
STEMI Systems of Care
PCIPCIcapable
Non-PCINon-PCIcapable
SYSTEMSYSTEM OF CARE OF CARE
CENTER OF CENTER OF CARECARE
CENTER OF CENTER OF CARECARE
Patient &Community
EMSED
STEMI Referral
STEMI Receiving
Awareness
Activate EMS
Avoid delay
12-lead ECG
9-1-1 inter-hospital transport
Activate team
No diversion
Treatment protocols and clinical pathways
Jacobs. Circulation 2007;116:217-230.
“STEMI Vision” –Just Say No!
95%+ of EMS calls are NOT STEMI!
Ab PainMVA
Weak/dizzy
???Altered
Need rideEtoh
STEMI
Chest Pain
The “STEMI/Sick Patient” Paradox…
Sick EMS patients (usually) look sick(trauma, VFIB, hypoxia, asystole)
Motto: Keep ‘em alive, & diagnose ‘em after arrival!
…Not so with STEMI!
Think Globally, Act Locally EMS STEMI
solutions must be locally driven based on national suggestions
Change items that really matter.
So, Where Do We Start?
4 a.m. Sunday night, Raining… Grandma’s house …44 miles out…
Got STEMI? –Call the ED!
EMS/ED communication on every potential STEMI is a must
Either with OR without ECG transmission
I think I got one!
D: Logging, Bad Burgers & “Angels”
34 year-old male is logging trees in remote area Increased heartburn after “gut bomb” lunch Later, his boss starts driving him to the hospital Pain worsens; His boss calls rural EMS, who
arrange to meet them at a local “KwikMart”. EMS does ECG in parking lot: it looks “bad” Idea: fax ECG to MedCom before departure
DX: Acute Inferior Wall MI! EMS departs for PCI center “Joe” at KwikMart faxes the ECG In route patient goes into VFIB arrest Defibrillated once with good results… EMS contacts PCI center in route;
discusses ECG with the ED physician (…NO TRANSMISSION) Cath lab activated, ED on Standby…
Post Cath
Madison County, VA “EMS Angels”